Provider Demographics
NPI:1013339563
Name:HAUGHTON, KELSEY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KELSEY
Middle Name:
Last Name:HAUGHTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:BLOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-3368
Mailing Address - Fax:
Practice Address - Street 1:1505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2913
Practice Address - Country:US
Practice Address - Phone:918-967-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant